Book Reviews
Understanding Health Inequalities
Hilary Graham (editor)
ISBN: 978-0-3352055-4-7 2000 227 pages Open University Press, Buckingham
John Germov
Senior Lecturer, The University of Newcastle
In recent years there has been renewed interest in public policy and social science research on health inequality, particularly stemming from events in the UK, such as the work of Marmot and Wilkinson, and the 1998 Independent Inquiry into Inequalities in Health (the Acheson report). Understanding Health Inequalities is part of this welcome trend and is a specific outcome of the UK Economic and Social Research Council (ESRC) Health Variations Programme (see www.esrc.ac.uk ).
The Programme was established in 1996 and funded 26 projects drawn from a broad multi-disciplinary base with researchers from sociology, social policy, social epidemiology, economics, geography, and psychology. The book reports some of the Programme's major findings in an attempt to examine the link between social inequality and individual health (p.3). To greater and lesser degrees the chapter authors attempt to grapple with the issues of combining structural and psychosocial approaches to understanding health inequalities.
The book consists of 13 chapters divided into a five-part structure that reflects the major themes of the funded projects. The introductory part consists of a single introductory chapter by the editor Hilary Graham. Graham presents a succinct overview of the evidence and issues in the health inequality literature, particularly as they relate to the chapters in the book. This is followed by the first substantive part of the book, which is made up of two chapters examining the links between ethnicity and health, and the third (and only) chapter exploring gender and health.
The two ethnicity chapters present a multi-layered and complex understanding of the links between ethnicity and health inequality by examining the way that ethnicity has been conceptualised and measured in health research. For example, research on ethnicity in the UK can often fall into the trap of 'pathologising' minority ethnic status. Furthermore, ethnic categories such as 'Asian' are often treated as unproblematic, whereby all those subsumed within an ethnic category are viewed as static and homogenous in terms of cultural beliefs, behaviours and lifestyles. These chapters highlight that differences in health status among some ethnic groups are related to wider problems of class inequality and discrimination rather than cultural differences.
The chapter on women and health inequality draws on Bourdieu in an attempt to blend material approaches to inequality with psychosocial approaches. What begins as an interesting discussion of different ways of examining the pathways between social inequality and health inequality, disappointingly fishtails into an epidemiological presentation of statistics (with an unspecified methodology) and virtually no discussion of gender. It is also noteworthy that this is the only chapter in the book that substantively attempts to address gender issues.
Part 2 of the book is made up of three chapters that explore the influence of lifecourse and biography on health disadvantage. The chapters in this part deal with health in early old age, the influence of income on health from childhood to adulthood, and barriers to health embedded in individuals' biography in terms of how family patterns of heart disease can influence health-related behaviour. The common conclusion from the chapters in this section is that health inequality can take root in childhood as well as during key life stages and events, resulting in lasting detrimental effects across the lifecourse.
Part 3, the largest section of the book, presents five chapters that concern the influence of housing, neighbourhood and geographic region on health inequality. An area-based approach to health inequality concerns the role played by public infrastructure as well as regional and community policies in determining health status. The chapters in this part cover issues such as differences in health status between renters and home-owners; the role of health-promoting neighbourhood features such as leisure avenues (parks and sports facilities) and safety (violence, discarded syringes…); as well as the influence of de-industrialisation and diminished social capital in explaining regional differences in health.
The final part of the book consists of one chapter that addresses the issue of evaluating the impact of public policy aimed at addressing health inequalities. This interesting chapter makes an original contribution to the field, but is hampered by an all too brief discussion of empirical findings. In fact, this is a criticism that can be applied to the book as a whole. While most of the chapters make worthwhile contributions to the field, the reader is left with the distinct impression that they are only getting part of the story, as the numerous references to journal articles 'in press' by the chapter authors infer - and one can't help but get the sense that the 'good stuff' is to be found there.
Despite what its title may imply, Understanding Health Inequalities does not attempt to provide comprehensive coverage of the topic. Its content is clearly limited to the funded projects of the ESRC programme and is particularly geared to a UK audience. Readers will be disappointed by the lack of an attempt at theoretical synthesis, as well as the marginalisation of gender, class and workplace issues (occupational health barely rates a mention). In the areas of ethnicity and the role of 'place and space' (housing, local communities and geographic regions), the book does make important contributions to the field. For these reasons, Understanding Health Inequalities would be of interest to Australian social scientists and postgraduates researching and teaching in the field. The attempts throughout the book at blending structural and psychosocial approaches to health inequalities, while laudable remained largely unfulfilled, but hopefully will inspire Australian researchers to take up the challenge.
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